Documentation Of The Medical Exam

Documentation of the Medical Exam

Created by The Lung Doctor for e-Medtools

Recognized Single Organ Systems Cardiovascular Ears, Nose, Mouth, Throat Detailed Detailed Eyes Anextended extendedexam examof ofthe theaffected affectedbody bodyarea area An ororgans/organ organs/organsystem systemand andanother another Genitourinary (Female) or symptomaticor orrelated relatedarea area symptomatic Genitourinary (Male) Hematologic/Lymphatic/Immunologic Musculoskeletal Comprehensive A general multi-system exam Neurologic A complete exam of an organ system and Psychiatric other related body areas or organ systems Respiratory Skin Mostlevels levelsrequire requireaaminimum minimumof ofaaDetailed DetailedExam Exam Most

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Multi-organ System Exam Detailed

≥3 vital signs ƒ ƒ ƒ ƒ ƒ ƒ ƒ

BP, sitting or standing BP, supine Pulse, rate and regularity Respirations Temperature Height Weight

≥2 elements* of at least 6 organ systems or body areas examined OR ≥1 element of at least 12 organ systems

Comprehensive

≥2 elements* in at least 9 organ systems or body areas *Referto to1997 1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services *Refer

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Single Organ System Exam Detailed ™ Document ≥12 elements* (NOT Eye and Psychiatric exams) ™ Eye and Psych exams document ≥9 elements

Comprehensive ™ Document ALL elements*

*Referto to1997 1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services *Refer

Created by The Lung Doctor for e-Medtools

Elements of Individual Organ Systems Constitutional ¾ Vital signs ¾ General appearance of patient ¾

Nutrition, Body habitus, Development, Deformities, Grooming

Eyes ¾ Inspection of conjunctivae and lids ¾ Exam of pupils and irises ¾ Ophthalmoscopic exam of optic discs

Ears, Nose, Mouth and Throat ¾ ¾ ¾ ¾

External inspection of ears and nose Otoscopic exam Assessment of hearing Inspection of nasal mucosa, septum, and turbinates ¾ Inspection of lips, teeth and gums ¾ Exam of oropharynx

Neck ¾ Exam of neck ¾ Thyroid

Respiratory ¾ ¾ ¾ ¾

Assessment of effort Percussion of chest Auscultation Palpation of chest

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Cardiovascular ¾ ¾ ¾ ¾ ¾ ¾ ¾

Palpation of heart Auscultation Carotid artery exam Abdominal aorta exam Femoral arteries exam Pedal pulses exam Extremities for edema or varicosities

Chest (Breasts) ¾ Inspection ¾ Palpation

Gastrointestinal ¾ ¾ ¾ ¾ ¾

Abdominal exam Liver and spleen exam Hernia presence or absence Anus, perineum, rectum exam Stool for occult blood

1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services 1997

Exam elements, continued Lymphatic

Psychiatric

¾ ¾ ¾ ¾

¾ ¾ ¾ ¾

Neck Axilla Groin Other

Musculoskeletal ¾ Gait and station ¾ Inspection, palpation digits and nails ¾ Exam of bones, joints, muscles AND 1 or more ¾ Inspection or palpation ¾ Range of motion and presence/absence of pain ¾ Stability ¾ Muscle strength and tone

Skin ¾ Inspection ¾ Palpation

Neurologic ¾ Cranial nerves ¾ Deep tendon reflexes ¾ Sensation

Created by The Lung Doctor for e-Medtools

Judgment and insight Orientation to person, time, place Memory, recent and remote Mood and affect

Genitourinary Male ¾ Scrotal contents ¾ Penis ¾ Digital rectal exam of prostate gland Female ¾ External genitalia ¾ Urethra ¾ Bladder exam ¾ Cervix ¾ Uterus ¾ Adnexa/parametria 1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services 1997